The fall of Roe v. Wade stands to dramatically shake up contraception trends. In the days following the US Supreme Court’s Dobbs ruling, clinics began to report a surge in people requesting tubal ligations—more commonly known as getting one’s tubes tied. This is a procedure in which the fallopian tubes are surgically blocked or sealed to prevent future pregnancies, one that is very difficult to reverse.

But those requesting the procedure often encounter a big barrier: doctors. Despite the American College of Obstetricians and Gynecologists (ACOG) advising that “respect for an individual woman’s reproductive autonomy should be the primary concern guiding sterilization provision,” people who can get pregnant are often refused the procedure. By and large, the decision still lies very much in the hands of the physician.

A doctor will typically refuse to perform a sterilization procedure on the grounds that the person is too young, that they don’t have enough children, or that they might come to regret the decision—or a combination of these factors. Without a partner or any children, a person’s chances of obtaining the procedure drop even lower. (There is no existing ethical guidance from the male counterpart to ACOG—the American Urological Association—on the provision of vasectomy services.)

The attitudes of today’s doctors are grounded in a history of pro-natalism that’s existed for decades in the United States. In the 1970s, the criteria for allowing sterilization were even stricter: A woman would be denied access to the procedure unless their age multiplied by the number of children they had equaled 120 or greater—if you were 40 years old with three children, you would be approved for the procedure, for example. In essence, a woman’s reproductive autonomy was decided on the basis of a mathematical calculation. Even today, doctors often require the sign-off of the patient’s partner.

Lisa Harris, an ob-gyn and professor at the University of Michigan, has seen an influx of young women requesting tubal ligations at her institution since the fall of Roe. Many of the patients have come to her after having been refused by other doctors. It’s a different manifestation of society not trusting women to know what they need, Harris says, and “probably related to the same distrust that leads to things like abortion bans.”

For Kayla, who lives in Chicago, a traumatic experience when she gave birth prematurely to her daughter last year meant she is sure she never wants to have another child. “I can’t see myself going through that again,” she told her doctor. When her physician suggested birth control, Kayla pleaded for something more permanent. “And she told me, ‘No, I’m too young … Maybe my daughter will want siblings.’” Since then, Kayla has visited at least three doctors requesting a tubal ligation, and all have refused, for similar reasons.

The concept of the risk of regret is a significant barrier to access and is based on the subjective opinion that people who can become pregnant will always want to bear children. In reality, this isn’t true. The largest study to look at rates of reported regret in sterilized women—the Collaborative Review of Sterilization—followed 11,000 sterilized women for 14 years after having the procedure. It found that childfree women who had been sterilized reported the lowest rates of regret among all groups of patients. “And yet this myth that women, especially women without children, will come to regret their decision to be sterilized persists,” says Elizabeth Hintz, an assistant professor of health communication at the University of Connecticut.

All of these reasons for denying sterilization are in direct contradiction of ACOG’s ethical guidance. Yet doctors face no repercussions for refusing to perform procedures; the US does not track data on how many sterilization requests are denied. “So there’s no accountability—there’s no capacity to enforce a consequence,” Hintz says.

Access to the procedure isn’t equitable across society. Echoes of sterilization’s checkered past—in which marginalized groups of women were forced to undergo the procedure, including women of color, women who were poor, and those living with disabilities or mental illnesses—still linger today. Black, Latina, and Indigenous women in the US are up to twice as likely as white women to be approved for sterilization, while women with public or no health insurance are about 40 percent more likely to have the procedure than privately insured women.

“The bottom line is that the way that this is legislated around—and the way that these very subjective sorts of assessments are able to be made—is just a means of perpetuating this very white, wealthy, able-bodied, and cisgender idea of who ought to have children,” says Hintz.

One corner of the internet in which those seeking the procedure can find advice and tips is the r/childfree community on Reddit. The subreddit has folders with extensive information on how to request the procedure, a collated list of doctors who will perform it, and a sterilization binder that members can take to their doctor with a template consent form and a form to list their reasons for wanting the procedure.

Alongside rising requests for permanent forms of birth control, the overturning of Roe has already triggered an uptick in the number of people seeking longer-lasting but nonpermanent birth control, such as intrauterine devices (IUDs). But the idea itself that birth control—permanent or otherwise—could replace access to abortion is inherently flawed, says Krystale Littlejohn, an assistant professor of sociology at the University of Oregon whose work explores race, gender, and reproduction. Despite the fact that the majority of people who can get pregnant use some form of birth control, one in four women will have an abortion in their lifetime. This is why the “just get your tubes tied” or “just get an IUD” rhetoric that has emerged in the wake of Dobbs isn’t helpful, she says.

For one, choosing these forms of birth control is not a trivial medical decision: Heavier, more painful periods and a potentially painful implantation procedure—often with no pain relief—are among the possible consequences of getting an IUD. Tubal ligations require an invasive surgical procedure and, as with any surgical procedure, can lead to complications.

In fact, the advice to use birth control can be seen as just another form of policing people’s bodies, Littlejohn says. “When it comes to people suggesting that their friends or their loved ones get on long-acting birth control, I think that people believe that they’re helping other people, but what they’re really doing is encroaching on their human right to bodily autonomy,” she says. Roe’s fall won’t just mean that people with uteruses are forced to give birth, she says; it’s also about compelling them to use longer-acting or permanent forms of birth control.

A person living in a restrictive part of the US may now feel compelled to seek out longer-term contraception or get their tubes tied—which is tantamount to compulsory birth control. “That’s not the solution right now,” she says. “I think it’s really important that we don’t try and fight reproductive injustice with reproductive coercion.”